| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,382 |
594 |
$159K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,536 |
2,534 |
$152K |
| D0120 |
Periodic oral evaluation - established patient |
2,605 |
2,592 |
$133K |
| D0210 |
Intraoral - complete series of radiographic images |
1,719 |
1,716 |
$78K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,891 |
3,746 |
$72K |
| D1120 |
Prophylaxis - child |
1,996 |
1,990 |
$71K |
| D0274 |
Bitewings - four radiographic images |
2,344 |
2,332 |
$47K |
| D0350 |
|
3,264 |
1,263 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,018 |
2,010 |
$22K |
| D0330 |
Panoramic radiographic image |
818 |
816 |
$22K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
305 |
136 |
$20K |
| D1110 |
Prophylaxis - adult |
257 |
256 |
$18K |
| D9430 |
|
402 |
397 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
142 |
75 |
$9K |
| D1351 |
Sealant - per tooth |
416 |
95 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
53 |
13 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
54 |
12 |
$5K |
| D2160 |
|
65 |
38 |
$5K |
| D4910 |
|
53 |
53 |
$4K |
| D4341 |
|
34 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
26 |
$2K |
| D9993 |
|
28 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
158 |
158 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$1K |
| D0272 |
Bitewings - two radiographic images |
122 |
121 |
$1K |
| D1310 |
|
28 |
28 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
27 |
27 |
$1K |
| D2140 |
|
13 |
13 |
$709.80 |
| D1354 |
|
13 |
13 |
$385.00 |
| D0603 |
|
26 |
26 |
$345.00 |